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Preventing a Clostriduim difficile Outbreak (Part 1)

Patrick Boshell
November 28, 2012
Preventing c difficile Outbreak

Bridgepoint Health in Toronto, Ont., is one of Canada’s leading medical facilities in understanding, treating and managing complex chronic disease – the number one health care challenge of the 21st Century. 

Since its inception in 1860, first as a House of Refuge for “incurables and the indigent poor,” Bridgepoint Health has continued to evolve meeting the most pressing health care issues of the time. The 404 bed facility has a support team that includes over 1400 staff, physicians and volunteers who are committed to changing the world for the thousands of inpatients and outpatients with complex chronic disease.

In keeping with the hospital’s commitment to changing the world, the hospital established an Elimination of Healthcare Associated Infections Committee to address the spread of infections. As part of this process a working committee to review Clostridium difficile Infection (CDI) was established. Since there have been numerous outbreaks in Ontario hospitals, the control of CDI was a high priority for both the Environmental Services (ES) and Infection Prevention and Control (IPAC) departments. 


Clostridium difficile (C. diff.), is a species of gram-positive bacteria that can cause severe intestinal disease. C. diff. is a serious cause of antibiotic-associated diarrhea which can lead to pseudomembranous colitis, a severe inflammation of the colon. This often results from eradication of normal gut flora by antibiotics.


In a very small percentage of the adult population, C. diff. bacteria naturally reside in the gut. Other people accidentally ingest spores of the bacteria while they are patients in a hospital, nursing home or other health care facilities. When the bacteria are in the colon because normal gut flora has been destroyed, C. diff. bacteria begin to grow releasing toxins that can cause bloating, diarrhea, fever, abdominal pain, etc. 


The infection control professionals at Bridgepoint Health began to investigate the best possible methods of preventing a CDI outbreak. Their process began with a review of recommendations made by facilities under the Niagara Health System, research of best practices from the Provincial Infectious Diseases Advisory Committee (PIDAC), a review of various other literature and journals, and an in-depth look at present Bridgepoint Health practices and challenges.


The hospital’s design is the first challenge since there are no private rooms, no hand washing sinks in patients’ rooms and washrooms are shared. A unit with up to 52 patients share four washrooms. Additionally, the hospital has inadequate storage space and clutter is an issue. Glo germ audits identified that the cleaning of shared equipment such as commodes is inadequate.


After the in-depth research, IPAC interventions were created. In additional to enhanced surveillance, a dedicated infection control professional (ICP) was named as the ES contact. With the formalities in place, the effort was then turned to the field staff in the form of training and education. 


Preventing CDI OutbreaksAs training programs unfolded, it was discovered staff felt their knowledge of CDI was basic. In fact, many thought of CDI as just diarrhea, and not an illness. Many more didn’t realize that C. diff. spores can live up to five months in the environment. Given this knowledge, a review of cleaning procedures for all staff was required.  


The CDI working committee highlighted the need for enhanced cleaning guidelines that included triggers calling for enhanced cleaning by the Environmental Services department. A newly created policy and procedure established that when four cases of CDI on a unit are identified, “enhanced” cleaning and/or increased intensity of cleaning is implemented.  


In addition, guidelines have been developed developed for using sporicidal cleaning products versus routine cleaning products. Enhanced cleaning by Environmental Services staff consists of twice daily cleaning, following a check list and using a sporicidal cleaning agent. Terminal and discharge cleaning is conducted after precautions are ceased.  


Purchasing sporicidal cleaning wipes made it easier for unit staff to clean commodes. A ‘Clean Seat Program’ was started with nursing staff and unit support technicians, and outlines the process in cleaning commodes after use and weekly cleaning. Pink tags were placed on chairs and a binder was created to monitor the number of chairs cleaned and type of cleaning conducted (i.e. weekly or terminal).


Environmental Services also created further interventions for the prevention of CDI outbreaks. The process began by fostering relationships through the training of clinical staff on cleaning practices and participating in unit-based huddles. Bridgepoint Health ES staff are viewed as leaders and educators in the importance for cleaning for infection control. As such they participate on numerous committees and are consulted frequently.


Training for ES staff has become a frontline tactic in the prevention of CDI outbreaks at Bridgepoint. Staff are mandated to utilize the PIDAC Best Practice Educational Tool Kit which reinforces proper cleaning procedures and use of cleaning products. In 2011, 65 staff completed the six modules and celebrated with certificates and cake.


Auditing has also become an important tool in the battle of infection prevention. A quality audit system was purchased and implemented in April of this year. Conducting routine equipment and environmental cleaning audits are part of the Hospital’s Quality Improvement plan for 2012 / 2013.  


The next steps for Bridgepoint Health include creating a mock CDI outbreak. To date, the hospital has never had a CDI outbreak, therefore, the lessons learned from this mock CDI outbreak will continue to enhance the present process. 


In April 2013 a new Bridgepoint Hospital is scheduled to open. The state-ofthe-art campus of wellness is specifically designed to meet the specialized needs of patients with complex chronic disease and will support Bridgepoint’s unique approach to patient care. The new building  design with washrooms, hand wash sinks and showers in each patient room will make a difference in infection control. With additional storage and up-to-date equipment, the hospital will be better prepared to stop the spread of infection.


By working together, the Environmental Services and Infection Prevention and Control departments will continue to be proactive by setting up great systems to identify concerns and to act quickly to resolve them.


This article is based on a presentation by Bridgepoint Health’s Jane Tooze, Infection Control Practitioner, and Barb Paul, Manager of Environmental Services, at the OHHA Conference and Trade Show in May.  Reprinted with permission.  Please visit for additional content.
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